SARTORIUS MUSCLE ROTATION-TRANSFER (SMRT) IN PROPHYLAXIS AGAINST GRAFT INFECTION AFTER REOPERATIVE GROIN VASCULAR PROCEDURES

Aim of Work: to study the feasibility of the use of sartorius muscle twist or SMRT as a prophylactic step against graft 
infection following reoperative vascular procedures of the groin, especially in diabetic patients. 
Patients and Methods: between March 1999 and December 2002 fifty eight patients in whom different vascular grafting 
procedures including anastomoses at the groin, presented with either graft thrombosis, haematoma or seroma in the groin during the first postoperative month and needed re-exploration of the groin. In 16 diabetic patients, sartorius muscle “twist” or SMRT was added at the end of the re-exploration (group A), while for the other 42 patients this procedure was not added (group B). SMRT was done by retraction of the upper end of the groin incision or extension of it upwards and laterally, and then the tendenous origin of the muscle is detached and the loose areolar attachments of the lateral portion of the muscle were incised and then it was rotated 180o along the medial border, so that the anterior surface of the muscle is now covering the femoral vessels. The proximal portion of the muscle was then sutured to the inguinal ligament and the “new” medial border was sutured to the perivascular or subcutaneous fascia. Suction drain was applied to drain the dead space at the original bed of the muscle. The number of vascular pedicles ligated in each case, the time needed to complete the SMRT procedure, any intraoperative or postoperative complications were recorded. Cases were followed up for a maximum of 6 months or until groin graft infection, secondary hemorrhage or thrombosis occurred. 
Results: In group (A) extension of the groin incision was needed in 38% of cases and in 56% of cases one vascular pedicle was ligated. The average time needed to complete the procedure was 22 minutes and there was no operative or postoperative mortality related to the procedure, however, wound haematoma occurred in one patient and it was drained. Only 14 patients were followed up, and of them one patient developed graft infection due to extension of infection from the subcutaneous track of in-situ saphenous bypass, while the other 13 patients passed very smooth postoperative course with healed groin incisions. 
In group (B), 39 patients were followed up. Graft infection developed in 23% of cases, treated with above knee amputation in 17%, with obturator bypass in 3%, and with ligation of the graft and the femoral artery above and below the anastomosis in 3%. 
Conclusion: sartorius muscle “twist” or SMRT is a useful procedure to prevent graft infection after reoperative vascular 
procedures of the groin, especially in diabetic patients. The procedure is easy to perform, safe and leaves the patient with no disability.